Latissimus Dorsi Flap Breast Reconstruction
Latissimus Dorsi Flap Breast Reconstruction is one of the latest techniques in breast reconstruction for patients with breast cancer. Breast reconstruction after mastectomy has evolved over the last century to be an integral component in the therapy for patients with breast cancer.
Breast reconstruction originally was designed to reduce post-mastectomy complications and to correct chest wall deformity, but its value has been recognized to extend past this limited view of use. The goals for patients undergoing reconstruction are to correct the anatomic defect and to restore form and breast symmetry.
The surgical options for breast reconstruction involve the use of endo-prostheses (implants), autogenous tissue transfers (e.g. using a muscle), or a combination of both.
Within the last 30 years, the technical emphasis has focused on the use of tissue expanders with implants, latissimus dorsi myocutaneous transfer (muscle from the back), and the transverse rectus abdominis myocutaneous (TRAM) flap (from the stomach) to achieve adequate breast restoration.
Although all of these methods are individually sufficient for reconstruction, surgical feasibility and patient preference dictate their use.
Reconstruction with the latissimus dorsi myocutaneous flap produces a breast with ptosis (natural droop) and projection while maintaining the natural consistency and feel of normal tissue. This flap provides ample bulk for reconstruction due to the large surface of the muscle.
In many patients, the flap can be used without the use of an implant, restoring volumes of up to 1.5 L in large patients or with the use of modified techniques. It restores the anterior chest wall with healthy tissue, particularly of benefit in patients who previously have undergone irradiation.
The flap also provides trophic stimulation to the surrounding tissues without increased disease morbidity or interference with mammographic evaluation.
Latissimus dorsi is a large, flat muscle in the back, which is moved to the site of the breast by swinging it around the ribcage so that it lies at the front of the body.
This method does not usually provide enough tissue to form the entire breast, so an implant or expander will also probably be needed, placed behind the muscle to help match the size of the remaining natural breast.
Scars from this type of reconstruction are relatively inconspicuous. In addition to the breast scar, there is a scar on the back, which can be almost horizontal, to hide under a bra-strap, or almost vertical under and just behind the armpit, to hide under a low-back evening dress.
Latissimus Dorsi is a pedicled flap, meaning that the blood vessels supplying the ‘flap’ of muscle and overlying skin remain attached to the body and continue to supply the flap in the same way when it is moved to its new site.
The tissue moved to create the breast is predominantly the muscle itself, but some skin can also be transferred to the new breast. This is particularly useful in immediate reconstruction, as a circle of skin, the same size as the mastectomy hole can also be moved, allowing the surgeon to close all wounds without stretching or distorting the remaining natural breast skin.
It also results in only one circular scar on the breast, around the nipple.
After Latissimus Dorsi flap reconstruction operation, the blood vessels supplying the muscle run from the back of the armpit to the chest, along with a protective cuff of muscle. This results in a ‘bulkier’ area under the armpit on the reconstructed side.
This will settle considerably during the first few months after the operation, as swelling subsides and the muscle cuff naturally thins, but will never disappear completely.
Latissimus Dorsi flap breast reconstruction offers good cosmetic results for women unable or unwilling to undergo abdominally-based breast reconstruction.
It provides a reliable breast mound using tissue from the back, the absence of which is well tolerated in almost all women. Only women who are active swimmers, rock climbers or tennis players may have difficulty due to the back weakness.
- Women who would like a more realistic reconstruction than is possible with an implant alone
- Women who would like to avoid large abdominal scars or risk reducing abdominal strength
- Women without enough abdominal fat to create a breast to match the remaining natural breast
- Women with small to medium volume breasts
- Women with considerable previous abdominal surgery or abdominal radiation
Operative Technique For Immediate Reconstruction
The operation is carried out in three stages. Firstly, the patient is placed on her back and the mastectomy performed. Any axillary surgery (sentinel node biopsy or axillary clearance) is performed at this time.
The second stage involves turning the patient on her side and “harvesting” the LD muscle.The pedicle (artery and vein to the flap) is identified in the armpit to avoid any inadvertent damage, and the muscle with its overlying piece of skin is lifted from the back, tunnelled through the armpit and swung round the ribcage to lie under the breast.
The third stage is then to turn the patient onto her back and the skin of the flap is trimmed to match the hole left by the mastectomy, Finally the breast is compared to the un-operated side and the muscle is sutured to create the contour of the breast mound.
If necessary, an implant is inserted. Drains are inserted in both the breast and the back wounds which are then closed, generally with dissolving sutures.
Operative Technique For Delayed Reconstruction
The operative technique is similar to immediate reconstruction except instead of mastectomy, in the first stage a pocket is created on the chest wall by raising soft tissue flaps at the site of the previous mastectomy.
At the second stage, harvesting of the LD is performed whilst the patient is on her side, and finally the third stage is again performed with the patient on her back. In the last stage, the LD flap is set in the pocket created in the first stage.
Complications You Should Be Aware Of:
Infection (5%) – this ranges from a superficial wound infection, easily treated with antibiotics, to an infection of the implant if one is used. Implant infections are especially troublesome as, generally, the implant must be removed to fully treat the infection, and re-inserted at a later date.
Bleeding (5%) – Although any bleeding points are cauterised during the procedure, it is possible that you may develop a collection of blood under the skin. Very occasionally, this can become infected or need to be let out by returning to theatre and re-opening the wound.
Seroma – this is a very common complication. If fluid continues to be produced after the drains are removed, it will collect under the skin and may become uncomfortable, but it can be easily and painlessly removed by sliding a needle through the scar on your back taking the fluid off with a syringe.
Flap Failure (less than 1%) – this is a very rare complication.
Revision Surgery – After the muscle is moved from the back to the front, it changes size over the first 3 months. Further small procedures may be required to improve the final outcome of your reconstruction.
Recurrence – Having a reconstruction would not stop a recurrence of the cancer in the skin that is left, if it were to occur.
(To view images of Latissimus Dorsi Flap Breast Reconstruction – Before & After Images click here or click the link below.
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